Mystery caller study finds German pharmacies often recommend unneeded emergency contraception

When a woman calls a German community pharmacy asking about the morning-after pill, she is more likely than not to receive a recommendation she does not medically need. That is the central finding of a nationwide mystery caller investigation, in which trained simulated patients contacted a stratified random sample of 376 community pharmacies across Germany to test whether staff follow the counseling checklist issued by the German Federal Chamber of Pharmacists (BAK). The study, conducted by Bernhard Langer and colleagues, found that oral emergency contraception was unnecessarily recommended in 49.1 percent of consultations, while only 44.4 percent of calls produced an appropriate outcome in which staff correctly recognized that the pill was not indicated.

The scenario behind the calls was deliberately subtle. Since 2015, oral emergency contraceptives have been available over the counter in German pharmacies without a prescription, making the pharmacy a first point of contact for urgent advice. Eight female mystery callers, aged 21 to 24, posed as users of a combined oral contraceptive who had forgotten to take one pill after sexual intercourse. Crucially, the missed pill could still be taken within the twelve-hour window permitted under the BAK guideline, meaning that taking the missed dose, rather than emergency contraception, was the appropriate response. Each call was monitored by a second observer to ensure the quality and consistency of the recorded data.

Of the 376 calls placed, 322 were included in the primary analysis. The simulated patient methodology used in the study is regarded as the gold standard for assessing real-world counseling behavior, because staff have no way of knowing they are being evaluated. The researchers scored each consultation on whether pharmacy staff asked the four checklist questions recommended by the BAK guideline, which are designed to establish whether emergency contraception is actually indicated. The median questioning score was just 2.0 out of 4.0 points, indicating that information gathering fell short of what the professional guideline prescribes.

A multivariable logistic regression model showed that two factors were significantly associated with an appropriate outcome: a higher questioning score, meaning staff asked more of the recommended checklist questions, and the identity of the mystery caller herself. The latter result surprised the research team. Some callers were systematically more likely to receive correct advice than others, and the authors call for further research into how vocal characteristics and last names might influence the quality of telephone consultations.

Qualitative findings from the calls painted a mixed picture. The researchers observed both positive counseling practices and notable deficiencies among pharmacy staff, ranging from thorough information gathering to premature recommendations made without establishing whether hormonal exposure was warranted. The authors note that unnecessary recommendations carry real costs: financial burden for the women involved, avoidable hormonal exposure, and potential side effects, without medical benefit in cases where emergency contraception is not indicated.

To address these deficits, the study makes two practical proposals. First, the consistent use of the BAK checklist during telephone consultations should be explicitly recommended in the relevant guideline, since the data link more complete questioning to better outcomes. Second, targeted training for pharmacy staff could help close the professional and communication gaps the investigation exposed. The findings suggest that when hormonal medication is dispensed without a prescription, asking the right questions before recommending treatment remains a decisive step, and one that German pharmacies currently missed in roughly half of the urgent telephone calls studied.

Subject of Research: Mystery caller investigation of emergency contraception counseling in German community pharmacies

Article Title: Do community pharmacies unnecessarily recommend oral emergency contraception? A nationwide mystery caller investigation in Germany

Article References: Langer, B., Beck, A., Dreier, A. M., Gabrieljan, R., Hilgenhof, H., Latuske, J., Priepke, C., Schaihadinow, K., Schwarz, H., & Kunow, C. (2026). Do community pharmacies unnecessarily recommend oral emergency contraception? A nationwide mystery caller investigation in Germany. PLOS One, 21(10), e0361027. https://doi.org/10.1371/journal.pone.0361027

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0361027

Keywords: emergency contraception, community pharmacies, mystery caller study, pharmacy counseling, Germany, over-the-counter medicines, simulated patient methodology, BAK guideline, information gathering, hormonal exposure, community, pharmacies